He’s overdressed in killing heat, the sun a screw that’s turned too tight, the air on fire, concrete a punishment. Some thing is done for him, extinguished, turned to ash. Desire looks gone from his worn face, his eyes like holes that sink in sand. Perhaps a junkie, dressed like that. Perhaps another crazy soul, whose home can never square with his address. Perhaps he’s twenty-three or four, an age when life should whistle through his bones. Across the bridge he hurries on, the cage surrounding him belongs to him, alone. And gone, an apparition passing by, the shape a man’s, who has, in some way, died.

Ed Hack was a teacher. Now he’s a poet. He’s been writing for years, published here and there, and, most recently, exploring the precision, passion, and forms of the sonnet. He is the father of the emergency medicine physician and toxicologist, Jason Hack, MD. When Jason asked his father why he would write a poem applicable to the experience of emergency medicine, he said, “I’ve lived it through your eyes and in the stories you have told me for the past twenty years.”

It was Saturday evening and Audrey G lay awkwardly on an emergency department stretcher in search of a comfortable position. She suffered from chronic hip pain, the unfortunate and unexpected effect of pelvic surgery. But her real chief complaint involved her drug-abusing husband, who that morning stole her recently filled bottle of oxycodone, an opioid pain medicine. Her story included the surgeon who doubted her pain and a year of failed therapies. Now only oxycodone touched the pain, or so she said, fighting back tears. The on-call physician didn’t know her and said to go to the ER.

Any decision that involves prescribing an opioid asks that I pivot in a space mined with judgment and peril. Studies show that four of five new heroin abusers began their habit by abusing painkillers, and opioid painkillers and heroin have a heavy hand in the 47,000 lives lost prematurely in a single year from drug overdoses.

To be an emergency physician requires, first and foremost, being a skilled story listener. Before I can fashion a response or formulate a plan, I must first understand the patient’s story. This isn’t earth-shattering news. Humans, a group that includes both physicians and patients, have been using stories for thousands of years to communicate, connect and forge relationships.Read the rest of this entry »

I’m an emergency physician and a writer of fiction, and there is an inherent paradox in these two activities. When writing, I work with words on a page to create lives that readers will hopefully care deeply about. Meanwhile, when I’m working in the emergency department, there are moments when I’m faced with real people experiencing real suffering and I wonder why I don’t care more.

The great writer Tobias Wolff once said, “When I sit down to write, I discover things that I have, for one reason or another, not admitted, not seen, not reflected on sufficiently.”

And that’s the essence and beauty of writing, whether it’s writing fiction, an essay, or random notebook scribbling. By laying down words into sentences and sentences into paragraphs, I find myself thinking differently, making previously unseen connections, and discovering untended fears and blemishes.Read the rest of this entry »

The tendency of a material to break under repeated stress. Nine A.M. after a long 12 hour overnight shift in the Emergency Department, I sit in front of my computer and stop to wonder if it’s possible for me to break under repeated stress. We hear stories of this or that ER doc who cracked under pressure and quit the field or the other ER doc who had a nervous breakdown in the ambulance bay. Eventually you start to wonder exactly how much repeated stress that might take.

We, as a society, can’t ignore these numbers: over 47,000 human lives lost prematurely in one year from drug overdoses, a 7% spike over the previous year, with opioid painkillers and heroin driving much of this tragic surge. If this trend isn’t disturbing enough, four out of five new heroin abusers began their habit by abusing painkillers.

These numbers have faces. Caring for patients who abuse and overdose from opiates and other drugs are a growing constant in my practice. Meanwhile, pain is a common reason why patients come to the emergency department and alleviating their pain, or making it bearable, might require an opioid painkiller.

This sets up a tense interior dialogue whenever I’m considering an opioid. Am I treating pain or feeding an addiction, or maybe both? Am I fulfilling a moral gesture by providing comfort to someone in distress or contributing to the supply chain in the illicit pill economy, or perhaps both? For this patient, on what side of the firestorm would I find the burn from being wrong most bearable?

These are often unanswerable questions, and stumbling to a response often leaves me sick with feelings of anxiety and inadequacy.Read the rest of this entry »

As a practicing emergency physician for the past 27 years, I have used technology to care for emergency patients in many different ways. Recently, I got a dose of technology from the other side. A college student, who was so intoxicated that her friends thought she might stop breathing, was brought by ambulance to our hospital. After a few hours, she sobered up enough to ask if she could take a selfie with me in the emergency department. Despite the great opportunity to be in a new realm of Facebook, Instagram, or Twitter friends, I politely refused. But, it got me thinking.

Surely, the mushroom cloud of selfies that is e-streaming around the planet can have more than a self-indulgent purpose. Can selfies be used to educate about health and promote healthy behaviors? Maybe I should have agreed to that selfie with the recovering college student while I held up a sign that said “Know Your Limits – Don’t Binge Drink!” Read the rest of this entry »

My grandmother was an aspiring mezzo-soprano opera singer in Italy before World War II. After the German Army was driven out of Naples, she met and later married an American GI, settling down in central Maine, where they started a family. Like many of the immigrants in the area, my grandparents worked in the local mills making everything from shoes to blankets. My grandmother never gave up singing and was renowned for stunning her coworkers with renditions of classic arias that rose above the rhythmic chatter of sewing machines and looms. I have rich memories from my childhood of Sundays with my Nonna. We would make fresh pasta and sauce together and her booming voice would saturate the kitchen with the melodies of her youth.

By comparison, my own musical career got off to a less impressive start. At times I “played” the piano, violin and even the recorder, all with little success. Then, quite by accident, I discovered vocal music. I had always liked theater, and when they needed singers for the school musical, I was cast in the show. From then on I was a singer, eventually landing a coveted spot in a summer supergroup of some of the best college a cappella singers in country. I accomplished all of this without formal vocal training or expertise in music theory. A childhood surrounded by musicians resulted in my learning to sing by ear. Without being able to read music, I could tell you what the next note would be because I knew which note “fit” the chord.

Looking back, my approach to clinical medicine in the emergency department, mirrored my early days in music: I practiced medicine by Read the rest of this entry »

Michael, a man in his late fifties, presented to my emergency department with left-sided arm and leg weakness suggesting a stroke. The symptoms began the night before, but he was still able to walk. He got himself to bed, neglecting to mention anything to his wife Dana. The next morning, he woke with a headache and his weakness had worsened. He was no longer able to escape his wife’s attention. On presentation, his blood pressure was markedly elevated at 207/112. His exam demonstrated mild left arm and leg weakness and subtle sensory changes. His workup was normal except a head and neck CT angiogram with scattered atherosclerotic disease, with no stenosis or brain ischemia. An aspirin was given and his blood pressure managed.

Michael had only visited with a physician twice in twelve years. His misconception of health as the absence of a named disease led him to avoid doctors. He, like so many of our patients, had central obesity, the result of a typical American diet and lack of exercise. He admitted to stress related to work. I learned weeks later that the source of much of his stress ran layers deep.

When I survey our academic emergency physicians each year about what they most enjoy about their jobs, the number one answer is always “clinical care” or “taking care of ED patients.” It doesn’t matter whether they’re administrators, educators, researchers or primary clinician-educators. They were drawn to emergency medicine by the broad and deep challenges that roll or walk through our doors. Caring for ill and injured patients efficiently and compassionately requires establishing trust with patients and families. Developing a diagnosis and treatment plan begins with tending to the patient’s story and the findings on physical exam. They really love bedside medicine, but find themselves pulled away from time with their patients.

At the risk of sounding curmudgeonly, I think that many medical “advances” threaten the basic bedside connection that is so essential to being a good emergency physician. Were I to ask my colleagues in the ED, “How many of you think the EHR has made you a better doctor?” I suspect the silence would be deafening. The demands of the electronic health record (EHR) mean that emergency physicians spend much more time palpating a keyboard than an abdomen or injured extremity. The words that we might have been sharing with patients are now often dictated into a microphone or worse, become lost in a train of expletives directed at an illogical, unruly EHR.

An observation that I and many of my emergency medicine colleagues have made about vacations: we need them. We need them for wellness, to recharge, to recover. Great saves, terrible tragedies, we witness it all and it can wear on you. Unfortunately, when vacation plans are made, it is not uncommon to find oneself working even more shifts before the break to offset our absence on the schedule, making the time away absolutely critical by the time it rolls around.

And so after ten shifts in thirteen days, I find myself exhausted, unprepared, nervous, on a hot, humid bus that is supposed to be taking us to the dock but instead slows unexpectedly. A land iguana, a golden brown ancient dinosaur, creeps off of the road into the side brush. Piling off the bus, we are directed toward a concrete platform adorned with huge lounging marine iguanas. I gather my belongings and catch myself from stumbling, nearly stepping on an iguana’s whiplike tail that seems to have appeared right next to me. It spits salt water at me in retaliation but does not move. Sally lightfoots scuttle along the jagged shore, red as the lava the rocks once were. When I ask which boat is ours, I am interrupted by shouts of “Blue footed boobie!” causing me to forget the question I just asked. This is the first hour in the Galapagos.